Provider Demographics
NPI:1982709614
Name:STEVEN D CORK D.O. PL
Entity Type:Organization
Organization Name:STEVEN D CORK D.O. PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-253-4546
Mailing Address - Street 1:724 S BEACH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5412
Mailing Address - Country:US
Mailing Address - Phone:386-253-4546
Mailing Address - Fax:386-253-2116
Practice Address - Street 1:724 S BEACH ST STE 2
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5412
Practice Address - Country:US
Practice Address - Phone:386-253-4546
Practice Address - Fax:386-253-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0184Medicare PIN